Herpeskeratitis B00.5

Herpeskeratitis is an infection of the cornea with the herpes simplex virus. It can involve the iris. Symptoms and complaints include foreign body sensation, tearing, photophobia and conjunctival hyperemia. Recurrences are common and can lead to corneal hypoesthesia, ulcerations, permanent scarring and reduced vision. Patients with severe autoimmune diseases (e.g. SLE) or with immunodeficiencies (e.g. AIDS patients) can lead to severe complicated herpes simplex infections of the eye (Li TH et al. 2019).

Classification (Holland EJ et al. 1999)

Superficial form with affection of the corneal epithelium (keratitis dendritica)

Deep inflammation of the corneal stroma (keratitis interstitialis)

HSV infection of the corneal endothelium Endotheliitis (disciform, diffuse, linear.)

Primary infection: The initial (primary) infection is usually an unspecific, self-limiting conjunctivitis, often in early childhood and usually without corneal involvement. If the cornea is involved, early symptoms include itching or burning of the eye with foreign body sensation, increased lacrimation, photophobia and conjunctival hyperemia. Sometimes, herpetic blepharitis is also present. The blisters heal after about a week without leaving scars.

Recurrent infection: Recurrence is usually in the form of epithelial keratitis with lacrimation, foreign body sensation and a characteristic lesion of the corneal epithelium. The corneal lesions resemble a branched branch (dendritic or serpentine) with button-like ends. They can be stained with fluorescein. Multiple recurrences lead to corneal hypoesthesia or corneal anesthesia (there is evidence of a decrease in corneal nerve fiber density, corneal nerve branch density, corneal nerve fiber length and corneal nerve total branch density) in lesional corneas (Danileviciene V et l. 2019), corneal ulcers, permanent scarring with reduced vision.

Stromal involvement: The disciform keratitis involves the corneal endothelium with priority. Disciform keratitis is characterized by a deeper, disc-shaped, circumscribed, edematous and cloudy corneal area. It is accompanied by anterior uveitis. Disciphoric keratitis often causes pain and loss of visual acuity.

The deep inflammation of the corneal stroma (stromal keratitis or interstitial keratitis) can cause necrosis of the stroma and severe pain, photophobia, foreign body sensation and reduced visual acuity.

The recurrent course of HSV infection of the eye with scarring, opacity and even blindness is the real problem of the infection (Harris KD 2019).

Further complications of herpetic keratitis can be cataract or glaucoma.

Slit-lamp examination: branched dendritic or serpentine corneal lesions (finding of dendritic keratitis); also possible is a disc-shaped, localized corneal edema and a corneal opacity with anterior uveitis (finding of disciform keratitis).

Systemic: Additive for local therapy oral Aciclovir p.o. or i.v. or Valaciclovir p.o. In rare cases, especially in immunocompetent patients, resistance to acyclovir may occur (Robinet-Perrin A et al). In these cases it is recommended to switch to Valaciclovir (Basak SK et al. 2019).

Surgical: Before starting drug therapy, careful debridement with a cotton swab.

In case of recurrent corneal opacity, a corneal transplant may be necessary.

Recurrent herpes simplex keratitis: Aciclovir 400 mg p.o. 5x/day; alternatively: Valaciclovir 1000 mg p.o. 2x/day.

Local virustatics: Topical Ganciclovir. Topical therapy with ganciclovir (0.15% gel every 3 h while awake; 5 times/day) is usually effective. Alternatively, topical therapy with aciclovir or trifluridine. Characteristic findings include a branching dendritic or serpentine corneal lesion (suggesting dendritic keratitis) or a disc-shaped, localized corneal edema and opacity with anterior uveitis (suggesting disciform keratitis).

Corticosteroidexterna: Corticosteroidexterna are contraindicated in epithelial keratitis. In a later stage they are indicated for the treatment of herpetic stromal involvement (disciform or stromal keratitis) or uveitis (e.g. prednisolone acetate 1% initially every 2 h; after 2-3 days every 4-8 h).

Adjuvant for photophobia: Atropine 1% or Scopolamine 0.25% 3x/day.

Under no circumstances should existing blisters, for example on the lip, be scratched open. Strict hygiene must be observed. Use your own towels and washcloths in the family. It is best to use disposable towels and washcloths to prevent further spread of the viruses.

Contact lens wearers: In the case of a herpes simplex infection, e.g. of the lips, care must be taken that contact lenses are not contaminated with the herpes simplex viruses. Before touching contact lenses with your fingers, your hands should be washed thoroughly and dried with a fresh, unused towel

Any dendritic erosion of the cornea in patients > 5 years (primary infection occurs almost exclusively in early childhood) corresponds with a high probability to herpetically caused keratitis (Bodack MI 2019). If the local findings are unclear, viral DNA can be detected by PCR from tissue material (Guda SJM et al. 2019). A virus culture from the dendritic lesion in question can also confirm the diagnosis.

If a herpes simplex infection of the eye is suspected, an ophthalmologist should take over the therapy regime. If the corneal stroma or uvea is involved, treatment by an ophthalmologist is mandatory.

1. Basak SK et al (2019) Recurrence of herpes simplex virus endotheliitis in a Descemet membrane endothelial keratoplasty graft: mimicking fungal interface infection. BMJ Case Rep 6:12.
2. Bodack MI (2019) Case Series: Pediatric Herpes Simplex Keratitis. Optom Vis Sci 96:221-226.
3. Danileviciene V et l. (2019) Corneal Sub-Basal Nerve Changes in Patients with Herpetic Keratitis During Acute Phase and after 6 months.Medicina (Kaunas) pii: E214. doi: 10.3390/medicina55050214.
4. Guda SJM et al (2019) Evaluation of multiplex real-time polymerase chain reaction for the detection of herpes simplex virus-1 and 2 and varicella-zoster virus in corneal cells from normal subjects and patients with keratitis in India. Indian J Ophthalmol 67:1040-1046.
5. Harris KD (2019) Herpes simplex virus keratitis. Home Healthc Now 37:281-284. https://www.ncbi.nlm.nih.gov/pubmed/31483360
6. Holland EJ et al (1999) Classification of herpes simplex virus keratitis. Cornea 18:144-154.
7. Li TH et al (2019) Risk of severe herpes simplex virus infection in systemic lupus erythematosus: analysis of epidemiology and risk factors analysis in Taiwan. Ann Rheum Dis 78:941-946.
8. Robinet-Perrin A et al (2019) Input of recombinant phenotyping for the characterization of a novel acyclovir resistance mutation identified in a patient with recurrent herpetic keratitis. Antiviral Res 168:183-186.